Q  What does HEDIS stand for?

A HEDIS is an acronym for Healthcare Effectiveness Data and Information Set; a set of health-care performance measures. The National Committee for Quality Assurance oversees the development, implementation and all facets of the HEDIS tool. HEDIS consists of 81 measures across five domains of care. The measures compare how well a health plan performs in areas of quality of care, access to care and member satisfaction with the plan itself.

Q Who utilizes the HEDIS tool?

A Health plans primarily use HEDIS, collecting and reporting data on the various HEDIS measures. With a defined set of measures, HEDIS permits a comparison of health-plan performance that’s consistent from plan to plan.
Health plans combine their HEDIS scores with Consumer Assessment of Healthcare Providers and Systems scores and NCQA Accreditation standards scores to receive a Health Insurance Plan Rating from the NCQA. The NCQA ratings list includes commercial payers, Medicare and Medicaid plans.

What type of rating do insurance plans receive?

A Health Insurance Plan Rating is a score from one to five in 0.5 increments, with five being the highest possible rating. This system is similar to CMS’ Five-Star Quality Rating System, although the CMS system only rates nursing homes.
Compared with other plans in their category, those that get a five are in the top 10 percent, those that get a four are above average, those that get a three are average, those that get a two are below average and those that get a one are in the bottom 10 percent.

Q What is the significance of the rating to a health plan?

A Consumers analyze the ratings of different health plans when either selecting a plan for the first time or considering switching plans. The ratings provide consumers with a clear picture of how the various plans perform in key quality areas.

Individual health plans can use their star ratings as marketing tools. For example,

“XYZ Medicare Preferred HMO plans and the XYZ Health Plan Senior Care Options Plan earned a 5 out of 5 Star Rating from Medicare for 2016. This is Medicare’s highest rating and makes these plans among the best in the country! In fact, out of nearly 400 plans rated for 2016, only 12 received a 5-star rating!”

Q How does the Centers for Medicare & Medicaid Services use HEDIS scores?

A CMS can impose financial and contractual penalties on health plans that score poorly on HEDIS measures and Star Ratings, while health plans with high ratings benefit with potential financial bonuses from the federal government. Plans with a score of four or higher are eligible for federal bonuses that run from millions to billions. A recent article from Kaiser Health News, also published in USA Today, describes some of the ways health plans improved their ratings and the return on investment for having done so.

Good or bad results provide a health plan with the opportunity to analyze its results and make improvements in the quality of care and services it provides to its members.

Q Are third party-payers required to submit HEDIS data to the NCQA?

A Yes. Private insurance plans with Medicare and Medicaid contracts are required to collect and submit HEDIS data as a component of their contracts. Without the data, a payer will not receive a rating, which is critical to its ability to sell its insurance plans.

Q How do ophthalmology and optometry play a role in HEDIS scores and Health Insurance Plan Ratings?

A One of the HEDIS measures is “Comprehensive Diabetes Care.” This measure requires health plans to gather data showing that their subscribers (patients) with diabetes get recommended screenings and exams. The 2016 measure includes:

• Hemoglobin A1c testing (HbA1c poor control >9, HbA1c control <8);
• Blood pressure control (<140/90 mmHg);
• Eye exam (retinal) performed; and
• Medical attention for nephropathy.

Because a retinal exam is required to meet this quality measure, ophthalmologists and optometrists are an integral part of achieving the quality measure.

Q How does the health plan know that the patient received these services?

A Claims submission data provides the necessary information to the payer to validate meeting the HEDIS measure. For example, a claim for a lab test with CPT 83036 or 83037 confirms that the patient’s A1c was tested. There are several other ways that the health plan confirms performance of an eye exam. Per HEDIS, any provider may submit codes to substantiate the retinal exam. Eye exam codes (920xx) or evaluation and management codes (992xx), paired with a diabetes ICD-10 code as well as the CPT Category II codes used in PQRS reporting of this measure all suffice to support that this component of the measure was satisfied. The Category II codes are:

• CPT II 2022F: Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed;
• CPT II 2024F: Seven standard field stereoscopic photos with interpretation by an ophthalmologist or optometrist documented and reviewed;
• CPT II 2026F: Eye imaging validated to match diagnosis from seven standard field stereoscopic photos results documented and reviewed; and
• CPT II 3072F: Low risk for retinopathy (no evidence of retinopathy in the prior year).

In addition, payers request provider medical records and conduct chart reviews to gather necessary data to report to the NCQA.

Q How do primary-care providers fit into this matrix if the primary objective is to have the plan receive a high rating?

A A provider can be removed from the payer’s provider panel for not participating in HEDIS data collection. Most, if not all, participation contracts require providers to make available the medical record information necessary for the payer to meet regulatory and accreditation requirements.

Q If ophthalmologists and optometrists can report on the eye exam component of the HEDIS measure, why are primary-care providers concerned about insufficient data being reported to the health plan for this measure?

A According to the Centers for Disease Control and Prevention, “The age-adjusted percentage of adults aged 18 years or older with diagnosed diabetes receiving a dilated eye exam in the last year was 57 percent in 1994 and 62.8 percent in 2010.” Other organizations report less than 50 percent of diabetics receiving an eye exam.

If 85 percent of diabetic patients see a physician regarding their diabetes, and, according to the CDC, only 63 percent of diabetics receive an eye exam, there’s a large gap in reporting to satisfy the HEDIS measure.

Q How are primary-care providers working to achieve compliant results to report?

A Some primary-care providers are incorporating technology in their offices that takes a retinal photograph. An ophthalmologist or an optometrist interprets the photograph remotely. This approach assures the primary-care provider that his diabetic patients are receiving the required component of the HEDIS measure.   

Ms. McCune is vice pres­ident of the Cor­coran Con­sult­ing Group. Con­tact her at